Including yourself, how many people live with you that are related by blood, marriage or decree of court?*

Include income from spouse and anyone else that is residing with you that you are related to by blood or marriage in the following:

Monthly Income:*

Estimate your gross family income: (past 12 months)*

Do you currently have an outstanding bill at Southwestern Community College?*

Yes

No

I'm not sure

Work History (Present or most recent)

Includes volunteer work, part-time/full-time and self employment.

Employer:*

City/State*

Job title:*

Last Wage Received: (per hour)*

Start Date:*

Total Hours: (per week)*

Are you currently employed or volunteering with this employer?*

Yes

No

Reason for Leaving: *

Education

Last grade completed:*

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

High School Diploma or HSED completed:*

Yes

No

In process

College Degree completed:*

Yes

No

In process

Other training certificate or credential:*

Yes

No

Name or type of certificate or credential: *

Have you previously attempted a non-credit certificate course from SWCC but did not complete?*

Yes

No

Unsure

Do you have a National Career Readiness Certificate?*

Yes

No

No, but I have already signed up to obtain the NCRC

Are you currently a student?*

Yes, full time student

Yes, part time student

No, I am currently not taking any formal classes

When are you available to take classes?*

AM only

PM only

I'm flexible and can rearrange my schedule to take classes

Other

Out of the following choices please pick one area that interests you the most: *

Healthcare

Manufacturing

Welding

Information technology

Truck driving/logistics

Other

Have you considered going to college to earn a degree? *

Yes

No

Maybe

How did you hear about GAP Tuition Assistance Program or the PACE Program?*

Southwestern Community College staff

Iowa Workforce Development Center staff

SWCC Website

Newspaper

Radio

Mailing

Posters

Other

What would you consider are your barriers to success? *

Criminal record/legal matters

Children/finding childcare/paying for childcare

Lack of reliable transportation

Alcohol or drug addiction

Finding time to further my education

Finances/not able to make ends meet

Housing/steady housing

Physical disability

Mental disorder (anxiety, depression, add)

Other

Are you or have you been in any stage of the criminal justice process?*

No

Unsure

Yes, please explain

Do you have any misdemeanor arrests or convictions?*

No

Unsure

Yes, please explain

Have you been convicted of a felony?*

No

Unsure

Yes, please explain

Are you involved in any pending legal actions?*

No

Unsure

Yes, please explain

Are you under any court orders?*

No

Unsure

Yes, please explain

Have you been, are you, or do you need to be involved in substance abuse treatment in order to obtain employment?*

Yes

No

Unsure

What other barriers do you think may interfere with your success, if any?

Applicant Agreement and Release of Information ConsentI certify the information I have provided during this application process is true to the best of my knowledge. I understand that I have received a list of countable and uncountable income. After reviewing this document one last time I again verify that I have given or will give all of the proper proof and documentation to the qualifying college for eligibility purposes. I am also aware that the information I have provided may be reviewed and verified and that I may have to provide documents to support this information. I allow release of this information for documentation purposes and to gain further information for eligibility purposes. Further, I understand that this information will be used to determine my eligibility for GAP Tuition Assistance and for the services that SWCC’s PACE Program could provide. I am aware that I am subject to immediate termination and that I may be prosecuted for fraud if I am found ineligible after enrollment. However, we note that your employment status could change after being enrolled, but if any changes in finances occur the program staff must be updated and notified for tracking purposes. I understand that eligibility for tuition assistance under this chapter shall not be construed to guarantee enrollment in any community college certificate program. Also, I authorize the use of my Social Security Number as an identifier for the program. Please enter your name below if you agree to the above statement. *